Low mood and catastrophising – one is bad, two is worse

ResearchBlogging.orgHaving pain that persists creates a lot of stress, but there are many people who can limit the effect on their life and carry on.  These people seem to return to their everyday activities even if their pain hasn’t settled.  Then there are the other people.  This group have much more trouble managing with their pain.  They have more disability, more distress, seek more treatments and the impact of their pain spreads from the direct effect on their life, to effects on people around them.

If we could identify, then treat the risk factors that can lead to trouble recovering from pain, we might be able to limit the long term effects that chronic pain can have on people and our community.  While maybe 25 years ago the factors were thought to be biomechanical, or things like the extent of tissue damage – and yes, these do have some effect – over time it has become clear that psychosocial factors play an important role.

“Psychosocial factors” were initially quite poorly defined, and covered a multitude of sins! And to be honest, the focus is very often more on the psychological than the social part of that group of factors, but over time the picture is becoming a little clearer.  More on the social factors later – today it’s about low mood and catastrophising.

Firstly, low mood.  It’s unsurprising that people with persistent pain can feel a bit depressed.  Some people feel a lot depressed.  Imagine having trouble sleeping, worrying about your health, your job security, having to go through many different assessments and investigations – and all the while that pain is there.  So it’s not a big shock to find that people with low mood are often more distressed, seek more treatment – and have greater disability than people feeling less depressed.  Low mood in the subacute phase of pain is associated with more disability 12 months later.  This is a finding from many different studies and suggests that treating low mood is really important.

Catastrophising too, has been identified as a risk factor for greater disability and distress.  Catastrophising is the tendency to “think the worst” and has been viewed as an independent risk factor for longterm disability for some time.

In this multi-centre study based in New Zealand, Sweden and Australia, individuals with sub-acute pain (back pain with duration of less than three months) completed several questionnaires.  It’s a little unfortunate that the two groups used different measures, but with some magic by numbers, the measures were thought to be comparable.

The pain catastrophising measures used, were the Pain Catastrophising Scale and Pain Response Self Statements, and have excellent psychometric properties.  In addition to this, participants completed either the Hospital Anxiety and Depression Scale (Swedish sample) or the Depression Anxiety Stress Scale (Australasian sample), both of which are measures of low mood.  The disability measures were selected questions from the Orebro Musculoskeletal Questionnaire (the four ADL questions) in the Swedish group, while the Australasian group completed the Roland-Morris Disability measure.

What the researchers found was that some individuals had only high catastrophising, some had only high depression scores, and some had both high catastrophising and high depression scores. Oh – and some had both low depression scores and low catastrophising.  Make sense?

A relationship between high scores on either catastrophising or depression with greater disability was found – but not only this, there was a relationship between having high scores on both depression and catastrophising and having greater disability.  It seems evident that having both low mood and catastrophising increases the risk of disability.

It’s a little more complex that this – in the group with high catastrophising and low depression, higher levels of disability were found than in the group with high depression scores and low catastrophising.  This suggests that catastrophising may have a greater effect on disability than depression.

While this isn’t really a new finding, it is an important one.  This study shows that irrespective of the measures used to identify catastrophising and low mood in people with chronic pain, there is an increased risk of disability in people who have both problems, and more importantly, this is now shown in three different countries.  While the total number of participants isn’t enormous (in the 100’s rather than 1000’s), it is still a significant finding.  It also shows that having catastrophising is potentially a more problematic issue than simply having low mood.

What should we learn from this?
I think it’s critical that treatment providers working with those who have subacute musculoskeletal problems routinely assess (or at least screen for) the presence of catastrophising.  While low mood is troublesome, it seems to have greater recognition amongst primary care clinicians than catastrophising, so low mood can be identified and treated reasonably readily.  Catastrophising isn’t quite so commonly recognised nor managed – and that makes the risk of long term disability much greater.

Once identified – catastrophising needs to be managed.  I’ve written about this a good deal recently, so I hope this post might encourage readers to consider what steps they can take to identify and treat the problem promptly – or refer on.

Linton, S., Nicholas, M., MacDonald, S., Boersma, K., Bergbom, S., Maher, C., & Refshauge, K. (2011). The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain, 15 (4), 416-422 DOI: 10.1016/j.ejpain.2010.08.009



  1. I think there’s much more to this than about just perceptions of physical pain. I suspect the effects of PTSD follow the same passages. There is a woman professor and psychologist from the Philippines who was awarded the lifetime award from the APA last weekend who has written about psychological processes and change movements as narrative of personality and social justice movements. I can provide her name in a week or so. She was visiting friends she met in Australia.

    1. There is a link between the neural pathways involved in experiencing pain and the same pathways associated with experiencing an event that might trigger PTSD. There are some researchers (Yunus for one) who believe there is a common central mechanism making people vulnerable to both – and to depression, irritable bowel syndrome, pelvic pain, fibromyalgia and so on. And of course people “make sense” of anything they experience or see other people experiencing, so narrative can be one way for them to do so.

  2. As a physiotherapist, I encounter “catastrophizing” by patients relatively often. You mention to “refer on”. I have often tried referral back to GP with limited longterm benefit – who is best to manage catastrophizers?

    1. Hi Helen, that’s an excellent question and the answer depends a good deal on where you live! In NZ, I’d be suggesting a referral to one of the interdisciplinary pain management centres in the country, while I’m aware that in other countries direct referral to a clinical psychologist, occupational therapist with experience in psychosocial management of pain, and even psychiatrist with a specific interest in pain management. Creating a “cyberteam” of like-minded clinicians who are prepared to learn about how each other works and to work together within a team might be one way to eventually develop an effective pain management team. I do think many GP’s feel quite stuck when trying to work with people who have chronic pain, so I can understand why some of them just don’t follow up with referrals. I wonder if a discussion by phone or face-to-face might help problem solve some solutions to help both clinicians and the patient.

  3. “A relationship between high scores on either catastrophising or depression with greater disability was found – but not only this, there was a relationship between having high scores on both depression and catastrophising and having greater disability. It seems evident that having both low mood and catastrophising increases the risk of disability.”

    It may also be evident from these results that having a disability increases the risk of having both low mood and catastrophising.

    1. Hi Jo
      I didn’t mention in my post that these researchers conducted a longitudinal study in which they found that high scores on catastrophising and depression predicted greater disability at follow-up 12 months later. They did control for disability at presentation in their calculations, and found that with both groups of patients, their was a significant increased risk of greater disability. I’m quoting here from the paper While there was some variation on different measures of disability/function between the two samples, the groups higher on either depression or catastrophizing still had worse outcomes at 1-year relative to those who had minimal depressed mood and pain catastrophizing at baseline

  4. Yes, I agree and have read that before. What this woman has done is to research movements of resistance to oppression both nonviolent movements and violent resistance. When I can find her work, I think it form a curious bridge to social action and offer us some new avenues.

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